Sligo Creek Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Takoma Park, Maryland.
- Location
- 7525 Carroll Avenue, Takoma Park, Maryland 20912
- CMS Provider Number
- 215327
- Inspections on file
- 17
- Latest survey
- October 21, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Sligo Creek Healthcare during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of exit-seeking behaviors eloped from the facility by accessing an unsecured laundry room exit that lacked a lock, alarm, or wanderguard sensor. The resident, who was wearing a wanderguard bracelet and had a care plan for wandering, was able to leave the premises undetected and was later found at a distant hospital after being seen at a nearby metro station. The facility was unaware of the elopement until notified by the resident's family.
A resident's medical records were not provided to a requester despite an initial request made while the resident was still alive. The facility's process required verification and approval, but the records were not released before the resident's death, and a subsequent request was denied pending additional documentation.
The facility did not thoroughly investigate abuse allegations by failing to assess cognitively impaired residents who were assigned to alleged perpetrators. In multiple cases, while law enforcement was notified and statements were collected from staff, residents, and cognitively intact individuals, cognitively impaired residents were not included in the investigative process.
The facility failed to monitor refrigerator temperatures and properly label resident food, with temperatures exceeding safe levels. Additionally, there was no process for cooling potentially hazardous food items, risking food safety for all residents.
The facility failed to follow enhanced barrier precautions and hand hygiene protocols for two residents with gastrostomy tubes, as staff did not wear required gowns and gloves. Additionally, the laundry room lacked proper separation of clean and dirty linens, with staff not using appropriate PPE. These deficiencies were noted by surveyors and reported to the facility's management.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in care. A resident's use of side rails was not documented in the care plan, another resident's therapy recommendations were not included, and a third resident's nutritional care plan did not reflect the goal of weight gain. Additionally, a resident's comprehensive care plan was not completed in a timely manner.
The facility failed to safeguard resident information and maintain accurate medical records, as seen in incidents involving a resident's confidential information left visible, conflicting MOLST forms for a resident, an error in documenting a resident's test results, and a code status change without proper certification. These deficiencies were confirmed by staff, including the DON and ADON.
The facility failed to educate and offer the current COVID-19 vaccination to four staff members and two residents, as no documentation was provided to show proof of immunization acceptance, refusal, or education. Despite requests from the surveyor, the administration was unable to produce the necessary records to demonstrate compliance with vaccination protocols.
The facility failed to conduct timely care plan meetings and update care plans for three residents. One resident did not have care plan meetings after MDS assessments, another had only one documented meeting since February 2024, and a third resident's care plan was not updated after a fall incident. The facility did not adhere to policies requiring care plan meetings regardless of resident attendance and failed to involve all necessary interdisciplinary team members.
A resident with a urinary catheter was observed in the activity room with an uncovered catheter bag, despite prior instructions to apply a privacy cover. This oversight was noted during a survey, highlighting a failure to maintain the resident's dignity.
The facility failed to provide information to two residents to formulate advanced directives. Despite having intact cognition and being their own responsible parties, these residents did not have advanced directives, and there was no evidence of follow-up or discussion during care plan meetings. The Social Services Director confirmed the oversight, and the Director of Nursing acknowledged the concern.
A facility failed to ensure an accurate MDS assessment for a resident by incorrectly documenting pressure ulcers as present upon admission. The resident's MDS assessment inaccurately noted two pressure ulcers, including a DTI, without supporting documentation prior to the assessment date. The MDS Coordinator confirmed the error, leading to the deficiency identified by the surveyor.
A resident with a history of stroke and dementia was not provided with activities that met their needs, as identified in the MDS assessment. Despite the care plan's goals for cognitive and social involvement, the resident was often observed in their room, and the facility lacked adequate documentation of activity participation. The Activities Director admitted to not attending care plan meetings regularly and acknowledged the need for improved documentation processes.
The facility failed to document and implement physician orders for three residents. A resident on opioids lacked a Naloxone order, another with a skin tear had no documented wound care orders, and a resident with a seizure disorder wore a helmet without documentation in the care plan. These oversights were confirmed by the DON.
A resident with a stage two pressure ulcer did not receive timely wound care treatment as recommended by a wound care specialist. Upon readmission, the resident's treatment orders were not documented for a week, and a recommended change in treatment was delayed by five days. The DON and ADON explained the process for obtaining new orders, highlighting a concern about the delay in implementing the specialist's recommendations.
A facility failed to implement therapist recommendations for a resident's restorative care following a stroke, resulting in inadequate documentation and inconsistent use of a prescribed splint. The resident, who had a contracture in the left hand, was discharged from OT with specific recommendations for ROM and a splint program, but these were not properly documented or followed. The GNA was unaware of the brace, and the Rehabilitation Director acknowledged the documentation was confusing and inaccurate.
A resident was observed using oxygen without a physician's order. The resident had been using oxygen since admission, but a review of their physician orders showed no order for oxygen use. A nurse confirmed the oxygen use, and both the incoming and interim NHAs acknowledged the lack of a physician's order.
A facility failed to ensure accurate medication reviews when a resident's discontinued antipsychotic medication was incorrectly documented as active by an NP. The NP admitted to overlooking the medication during reviews, leading to a deficiency identified in a recertification survey.
A resident was not documented as being seen by a physician for over nine months. Despite claims of visits, the facility could not provide evidence of physician documentation from March to November. Inconsistent author identification in progress notes further complicated the issue, and the facility failed to resolve the documentation deficiency.
The facility failed to administer medications according to physician's orders for three residents, leading to a deficiency. A resident received Amlodipine Besylate despite having blood pressure and heart rate below the specified parameters. Two residents were given Lisinopril and Hydralazine outside the ordered parameters. The DON confirmed the absence of documentation authorizing these actions.
The facility failed to secure medications and maintain proper temperature controls. A CMA left a medication cart unlocked and unattended, and an insulin pen was left unattended on a cart. Additionally, refrigerators storing insulin had improper temperature readings, with one reading as low as 10-20 degrees Fahrenheit. The DON and other staff confirmed these deficiencies.
A resident experienced mouth pain due to dental issues, and a previous examination recommended surgical extraction. However, the facility failed to ensure the resident received the necessary dental services due to insurance coverage issues, and no alternative services were sought.
The facility failed to accurately assess resident needs, as the Facility Assessment incorrectly listed 'N/A' for residents requiring ostomy care, despite evidence to the contrary. The NHA admitted the assessment was outdated, and the DON was unable to provide an updated version, highlighting documentation and communication issues.
The facility's walk-in freezer was not maintained in a safe condition, as observed during a kitchen tour. Frost build-up around the door and difficulty in closing and latching the door were noted. The FSD mentioned an upcoming renovation and the facility's age. The DON acknowledged the concern.
The facility failed to provide residents with written notifications of grievance resolutions. A review of 18 grievance forms showed no documentation of residents receiving or agreeing to resolutions. The Social Service Director signed in the space meant for residents, and the DON was unaware of the requirement for written notifications. The facility's policy required a written decision to be issued, which was not followed.
Elopement of Cognitively Impaired Resident Due to Unsecured Exit
Penalty
Summary
A cognitively impaired resident with a Brief Interview for Mental Status (BIMS) score of 5, indicating severe impairment, and a documented history of exit-seeking behaviors, was able to elope from the facility. The resident had previously been assessed as an elopement risk and was wearing a wanderguard bracelet. Despite these precautions, the resident was observed on camera footage moving from the second floor to the first floor, attempting to exit through a locked door, and then accessing an unlocked service hallway via double doors. The resident subsequently entered an unlocked laundry room, where an exit door without a lock, wanderguard sensor, or alarm provided direct access outside. The laundry door had been left unlocked by a staff member, and at the time, could only be locked with a key. The resident was last seen in the facility around 10 AM after receiving medication. The facility became aware of the elopement only after being notified by the resident's family member, who had been contacted by a bus driver at a nearby metro station. The resident, found at the bus terminal, expressed confusion about their location and requested assistance in returning home. The resident left the bus terminal before the family member arrived and was later located at a hospital in another district, having traveled a significant distance from the facility. Interviews and record reviews confirmed that the resident's care plan included interventions for wandering, such as providing diversions and structured activities. However, the physical security measures in place were insufficient, as the resident was able to bypass locked doors and exit through an unsecured area. The incident was determined to meet the federal definition of Immediate Jeopardy Past Non-compliance due to the facility's failure to prevent the elopement of a resident assessed as high risk.
Removal Plan
- Replaced the laundry entry door with a self-locking door.
- Bolted shut the exit door located inside of the laundry room where the Resident exited the facility.
- Reassessed all elopement risk residents and tested the wanderguard functionality on all residents with wanderguard bracelets.
- Completed in-service education for all staff on elopement, wandering, and monitoring.
- Environmental Service Director (EVS) completed in-service on safety procedure in laundry area.
- Ordered a maglock to secure and lock the double doors of the service hallway and installed it.
- Random audits to be performed on elopement risk residents and staff implementing interventions, with findings submitted to the QAPI committee for review and further recommendations.
- Director of Nursing (DON) and/or Assistant Director of Nursing (ADON) will audit for proper transcription of the wanderguard orders, elopement risk assessment presence, and care plan update for new residents identified to be a risk, with findings submitted to the QAPI committee for review and further recommendations.
- Engineering Director will audit the exit doors to ensure they are always locked, with findings submitted to the QAPI committee for review and further recommendations.
Failure to Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide a resident's medical records upon request, as required. The complainant initially requested the medical records for a resident while the resident was still alive, but the facility did not fulfill this request at that time. The process described by the medical records staff involved verifying authorization, having the requester complete a form, and then sending the request to corporate and a legal firm for approval before releasing the records. Despite this process, the records were not provided to the complainant after the initial request. After the resident passed away, the complainant made a second request for the medical records. At this point, the facility required the complainant to provide a letter of administration due to the resident's death. Both the medical records staff and the DON confirmed that the initial request for records was made prior to the resident's passing, but the request was not fulfilled at that time. This sequence of events led to the deficiency identified during the survey.
Failure to Assess Cognitively Impaired Residents During Abuse Investigations
Penalty
Summary
The facility failed to ensure a thorough investigation was completed for allegations of abuse involving multiple residents. In one incident, a resident reported that two nursing assistants entered the room, physically assaulted the resident, and broke the resident's phone. While the facility's investigation included law enforcement notification and statements from the resident, alleged perpetrators, staff, and cognitively intact residents, it did not include assessments of cognitively impaired residents who were assigned to the alleged perpetrators. In another incident, a registered nurse observed one resident hitting another on the head with an object. The facility obtained staff statements and notified law enforcement but did not interview or assess other residents who may have interacted with the alleged perpetrator. In a third case, a resident reported being slapped and restrained by a GNA during care. The investigation again included law enforcement notification and statements from relevant parties, but failed to assess cognitively impaired residents assigned to the alleged perpetrator. The Director of Nursing acknowledged that cognitively impaired residents had not been included in these investigations.
Deficiencies in Food Storage and Cooling Processes
Penalty
Summary
The facility was found to have deficiencies in its system for monitoring the temperature of unit refrigerators used to store resident food brought in from outside sources. During observations, it was noted that three out of three refrigerators in resident areas did not have temperature logs, and the temperatures were above the recommended 41 degrees Fahrenheit, with readings of 45 and 49 degrees. Additionally, food items in these refrigerators were not properly labeled with names, dates, or room numbers, and there was no thermometer in the activity refrigerator. Staff members were unclear about their responsibilities for monitoring these refrigerators, leading to a lack of consistent oversight. Further inspection revealed that the facility did not have a process in place to monitor the cooling of potentially hazardous food items. During an inspection of the stand-up refrigerator, several cooked food items were found without documentation of a cool-down process. The Food Service Director admitted that there was no system for monitoring the temperatures of cooked food items during cooling, despite being aware of the regulation. This lack of a cool-down process could potentially affect the safety of the food served to residents. The deficiencies observed have the potential to affect all residents, as the improper storage and cooling of food items can lead to foodborne illnesses. The facility's failure to implement effective temperature monitoring and labeling systems for resident food storage, as well as the absence of a cool-down process for cooked food, highlights significant gaps in their food safety protocols.
Infection Control Deficiencies in Resident Care and Laundry Handling
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions and hand hygiene protocols, as observed in the care of two residents. One resident, who had a gastrostomy tube, was not provided care with the required gown by a geriatric nursing assistant during a bed bath. The assistant admitted to forgetting to wear the gown, which is a part of the enhanced barrier precautions outlined in the resident's care plan. Another nurse was observed removing a gastrostomy tube feeding without performing hand hygiene or wearing the necessary gown and gloves, despite the resident being on enhanced barrier precautions. In the laundry room, the facility did not maintain proper separation and handling of clean and dirty linens, which could lead to cross-contamination. The surveyor observed that clean linens were stored in an unmarked container without a lid, close to the dirty laundry bin. Staff responsible for laundry handling did not wear appropriate personal protective equipment, such as gowns and gloves, when processing dirty laundry. The Environmental Services Director confirmed that there was no physical barrier between clean and dirty areas and that staff were expected to wear PPE, which was not being followed. The facility's policies and procedures for enhanced barrier precautions and standard precautions, including hand hygiene and laundry handling, were not consistently followed. The lack of adherence to these protocols was evident in both resident care and environmental services, as staff failed to use the required protective equipment and did not maintain proper separation of clean and dirty linens. These deficiencies were brought to the attention of the Director of Nursing and the Environmental Services Director during the survey.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for several residents, leading to deficiencies in care. For Resident #66, the facility did not document the use of side rails in the care plan, despite an assessment indicating their use for bed mobility. The Director of Nursing acknowledged that while assessments were conducted, the care plan was not updated to reflect the use of side rails, which is a requirement according to the facility's policy. Resident #19, who had a history of cerebral infarction resulting in muscle contracture, was discharged from occupational therapy with recommendations for a restorative range of motion and splint program. However, the care plan did not include these recommendations, and the Rehabilitation Director confirmed that the recommendations were not incorporated into the care plan or nursing tasks, indicating a lapse in communication and implementation of therapy recommendations. For Resident #2, who had diagnoses of diabetes and malnutrition, the care plan did not reflect the goal of weight gain despite a dietitian's assessment indicating the need for a weight gain plan. The care plan contained outdated goals related to obesity, and there was no evidence that the dietitian participated in care plan meetings. Additionally, Resident #352's comprehensive care plan was not completed in a timely manner, as it was finalized several weeks after the initial assessment, which the Director of Nursing confirmed as a failure on the facility's part.
Deficiencies in Safeguarding Information and Maintaining Accurate Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain accurate and current medical records, as evidenced by several incidents involving multiple residents. In one instance, a Certified Medicine Aide (CMA) left a computer screen open with Resident #55's confidential medical information visible on a medication cart in the hallway, unattended. This was confirmed by the unit manager, who acknowledged that the CMA should have secured the computer before walking away. The Director of Nursing (DON) was informed of this breach of confidentiality but provided no additional information. Another deficiency involved Resident #51, whose electronic health record (EHR) contained two active Medical Orders for Life-Sustaining Treatment (MOLST) forms with conflicting code statuses. The Licensed Practical Nurse (LPN) assigned to the resident was initially unaware of the discrepancy and indicated that the resident's code status needed updating. Upon further review, it was found that the MOLST indicating a full code was voided, but the EHR still showed conflicting information. The DON acknowledged the issue and noted that the facility had already identified concerns with record discrepancies between the hard chart and EHR. Additionally, Resident #16's medical records contained an error in documenting a positive test result for Respiratory Syncytial Virus (RSV) when the resident was only positive for influenza A. The Assistant Director of Nursing (ADON) confirmed the documentation error. Furthermore, Resident #66's code status was changed to Do Not Resuscitate (DNR) without proper certification of medical ineffectiveness by two physicians, as required by the Health Care Decisions Act. The DON later provided the necessary certifications, but they were not completed prior to the code status change.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to provide education and offer the current COVID-19 vaccination to both staff and residents, as evidenced by the lack of documentation for four staff members and two residents. During the survey, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unable to provide records showing that Staff #28, #29, #30, and #31, as well as Residents #66 and #48, had been educated about or offered the COVID-19 vaccine. The surveyor's review of employee health files and resident medical records revealed no proof of immunization acceptance, refusal, or education. Despite multiple requests from the surveyor, the facility's administration did not provide the necessary documentation to demonstrate compliance with COVID-19 vaccination protocols. The ADON attempted to locate the records but ultimately failed to produce any updated information regarding the vaccination status or education for the involved staff and residents. At the time of the survey exit, no additional documentation was provided to address the deficiency.
Failure to Conduct Timely Care Plan Meetings and Updates
Penalty
Summary
The facility failed to conduct comprehensive care plan meetings at the required intervals and did not update care plans following changes in residents' status. This deficiency was identified for three residents during a survey. For one resident, the facility did not hold care plan meetings following the completion of Minimum Data Set (MDS) assessments in September and December 2024, despite the resident's complaints about the comprehensiveness of their care plan. The Social Service Director confirmed that the meetings were not held, even though facility policy mandates that care plan meetings should occur regardless of resident attendance. Another resident, with a medical history of dementia, had only one documented care plan meeting since February 2024, despite having MDS assessments in May, August, and November 2024. The facility failed to reschedule a care plan meeting initially planned for August 2024, and there was no documentation of the resident or their representative agreeing to meetings held before the completion of assessments. Additionally, the registered dietician did not attend the care plan meetings, and there was a lack of documentation regarding the resident's invitation to these meetings. The third resident's care plan was not updated following a fall incident in November 2021, which resulted in hospitalization. The Director of Nursing confirmed that the facility did not update the resident's fall prevention care plan after the incident. This oversight indicates a failure to revise care plans in response to significant changes in a resident's condition, which is a critical component of ensuring resident safety and care quality.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to maintain a resident's dignity by not ensuring that a urinary catheter bag was covered with a privacy cover. This deficiency was identified during a random observation of a resident who had a urinary catheter for at least six months. The resident was observed sitting in a wheelchair in the activity room with a partially filled urinary catheter drainage bag hanging on the side of the wheelchair without a privacy cover. Despite prior instructions from the nurse to the geriatric nursing assistant to apply a privacy bag, this action was not completed, leading to the deficiency being noted by the surveyor.
Failure to Provide Information on Advanced Directives
Penalty
Summary
The facility failed to ensure that information was provided to residents to formulate an advanced directive, as evidenced by the cases of two residents. An advanced directive is a legal document that specifies a person's wishes regarding medical treatment if they are unable to make decisions for themselves. During the survey, it was found that Resident #1 had a document in their chart indicating the right to formulate an advanced directive, but it was marked that the resident did not have one, despite expressing a desire to proceed with social services. Similarly, Resident #10, who had intact cognition and was their own responsible party, also lacked an advanced directive. The Social Services Director (SSD) reported that she asks about advanced directives upon residents' admission and provides information if they wish to create one. However, upon reviewing the records of Residents #1 and #10, the SSD confirmed that neither had advanced directives and there was no evidence of follow-up or discussion during care plan meetings. The Director of Nursing (DON) acknowledged the concern that the facility did not ensure information was provided to these residents to formulate advanced directives.
Inaccurate MDS Assessment for Pressure Ulcers
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident regarding the documentation of pressure ulcers. The resident was readmitted to the facility after a hospitalization and had an MDS assessment with an assessment reference date of January 7, 2025. The MDS assessment inaccurately documented that the resident had two pressure ulcers present upon admission, including a stage two pressure ulcer and an unstageable Deep Tissue Injury (DTI). However, a review of the medical record did not reveal documentation supporting the presence of the DTI prior to the assessment date. The wound specialist nurse practitioner's assessment note on January 7, 2025, documented a left heel pressure ulcer identified as a DTI, but there were no treatment orders for the DTI prior to January 8, 2025. The MDS Coordinator confirmed that the pressure ulcer was incorrectly marked as present on admission and that the treatment order for the DTI was placed after the resident's assessment. This discrepancy in documentation led to the deficiency identified by the surveyor.
Failure to Provide Resident-Specific Activities
Penalty
Summary
The facility failed to provide activities that met the needs of a resident with a history of stroke and dementia. The resident had been at the facility for approximately one year, and the Minimum Data Set (MDS) assessment indicated that music and getting fresh air were very important to them. Despite this, observations by the surveyor showed the resident frequently remained in their room, often in bed, and not participating in activities. The resident's representative expressed concerns about the lack of participation in activities. The activities care plan for the resident included goals for involvement in cognitive stimulation and social activities, with specific interventions such as watching movies or attending social hours. However, the Activities Director noted that the resident chose not to participate in the activity program and preferred to stay in their room. The facility's documentation practices were inadequate, as there were no records of 1:1 visits or specific participation in activities, and the attendance logs were not maintained in the medical record system. The Activities Director admitted to not regularly attending care plan meetings and acknowledged the need to revise the current process for documenting activities participation. The documentation provided was insufficient, lacking specific details such as dates, times, or types of activities. The facility failed to demonstrate that the resident was offered individualized activities that were important to them, as identified in the MDS assessment.
Failure to Document and Implement Physician Orders
Penalty
Summary
The facility failed to ensure that physician orders were properly documented and implemented in the electronic health record for three residents. Resident #12, admitted for rehabilitation, had several orders for opioid medications. A pharmacist recommended, and a physician agreed, that Naloxone should be ordered for potential opioid overdose. However, the order for Naloxone was not found in the resident's records until several days later, indicating a lapse in the facility's pharmacy review process. Resident #30, also receiving rehabilitation, had a skin tear on the right inner thigh. The Nurse Practitioner provided orders to clean the wound and apply specific dressings. However, these orders were not documented in the resident's records, and there was no evidence in the Medication Administration Record or progress notes that the wound care was performed as ordered. This oversight was confirmed by the Director of Nursing during an interview. Resident #66, with a history of subdural hemorrhage and seizure disorder, was observed wearing a helmet for protection. Despite the helmet's use, there was no documentation in the medical record or care plan regarding its necessity. The GNA responsible for the resident's care was aware of the helmet's purpose but noted that it was not included in the care plan. The Director of Nursing and Assistant Director of Nursing acknowledged the helmet's use but failed to ensure proper documentation until after the surveyor's observations.
Delay in Implementing Wound Care Recommendations
Penalty
Summary
The facility failed to implement wound treatment recommendations in a timely manner for a resident with a pressure ulcer. The resident was readmitted to the facility after a hospitalization and had a stage two pressure ulcer upon admission. However, the Treatment Administration Record did not show any treatment orders for the pressure ulcer from the time of admission until a week later. On January 7th, a wound care specialist recommended a specific treatment for the resident's sacral wound, which was implemented the following day and continued until January 19th. On January 14th, the wound care specialist recommended a change in the treatment for the resident's unstageable sacral pressure ulcer, which included the use of Med-honey and calcium alginate. Despite this recommendation, the new treatment order was not entered until five days later, on January 19th. The delay in implementing the wound care specialist's recommendation was discussed with the Director of Nursing and the Assistant Director of Nursing, who explained the process of obtaining and following through on new orders. The surveyor noted the concern regarding the delay in initiating the recommended treatment.
Failure to Implement Therapist Recommendations for Restorative Care
Penalty
Summary
The facility failed to implement an effective system to ensure that therapist recommendations for a resident's restorative care were followed. Resident #19, who had a history of cerebral infarction resulting in contracture of the left hand muscles, was discharged from occupational therapy with specific recommendations for a restorative range of motion (ROM) and a splint and brace program. However, there was no documentation in the medical record indicating that the resident was referred for these restorative programs, nor were there any care plan interventions, physician orders, or nursing assistant tasks specific to the resident's needs. Observations and interviews revealed that the resident was not consistently wearing the recommended splint, and the Geriatric Nursing Assistant (GNA) was unaware of the brace. The GNA reported that the resident often refused ROM exercises due to pain, and this was communicated to a nurse. The Rehabilitation Director confirmed that the facility's documentation was confusing and did not accurately reflect the therapy recommendations. The facility's failure to ensure the implementation of the therapist's recommendations was confirmed by the Director of Nursing.
Failure to Obtain Physician's Order for Oxygen Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of oxygen for a resident. On February 10, 2025, a resident was observed using an oxygen nasal cannula connected to an oxygen concentrator set at 1 liter/minute. The resident reported using oxygen since their admission in January. A review of the resident's physician orders on February 13, 2025, revealed no order for oxygen use. The resident was again observed using oxygen at the same setting later that day. A registered nurse confirmed the oxygen use, and both the incoming and interim nursing home administrators acknowledged the absence of a physician's order for the resident's oxygen use.
Inaccurate Medication Review by NP
Penalty
Summary
The facility failed to ensure accurate medication reviews for a resident, leading to a deficiency identified during a recertification survey. A resident had been prescribed quetiapine, an antipsychotic medication, for agitation, which was discontinued on December 26, 2024. However, subsequent clinical notes by a Nurse Practitioner (NP) on January 31, 2025, and February 10, 2025, inaccurately documented quetiapine as an active medication. During an interview, the NP acknowledged the error, attributing it to an oversight in reviewing the resident's medication records. The Nursing Home Administrator was informed of the inaccurate evaluation but did not provide additional information.
Failure to Document Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician for more than nine months. Specifically, Resident #2's medical records did not contain documentation of visits by a primary care physician or nurse practitioner from March 2024 through November 2024. The Director of Nursing and Assistant Director of Nursing were informed of this issue, and the Assistant Director of Nursing attempted to verify the records but was unable to find the necessary documentation. Despite claims that the resident was seen by a physician, the facility could not provide evidence to support these visits. Further investigation revealed that Nurse Practitioner Progress Notes were present for August 2024, but the author was inconsistently identified as a physician, physician assistant, and nurse practitioner. The Nursing Home Administrator clarified that Staff #33, who authored the notes, was a nurse practitioner. However, the facility still failed to provide documentation confirming that a physician saw the resident during the specified period. As of the survey's conclusion, the facility had not resolved the documentation deficiency, leaving the issue unaddressed.
Failure to Administer Medications According to Physician's Orders
Penalty
Summary
The facility failed to administer medications according to the physician's ordered parameters for three residents, leading to a deficiency in medication management. Resident #51, who had been residing in the facility since 2023, was prescribed Amlodipine Besylate for hypertension with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 or the heart rate (HR) was less than 60. However, the medication was administered multiple times in January and February 2025 when the resident's SBP and HR were below the specified parameters. The Director of Nursing (DON) could not find any documentation indicating that the physician had authorized administration outside these parameters. Similarly, Resident #48, admitted in early 2023, had orders for Lisinopril and Hydralazine with instructions to hold the medications if the SBP was less than 110 or HR was less than 60. Despite these instructions, the medications were administered on several occasions in January 2025 when the resident's HR and SBP were below the specified limits. The DON reviewed the records and confirmed the absence of any notes authorizing administration outside the parameters. Resident #12, admitted for rehabilitation, was also affected by this deficiency. The resident was prescribed Amlodipine Besylate with instructions to hold the medication if the SBP was below 110. The medication was administered outside these parameters six times in January 2025 and twice in February 2025. The DON confirmed the concerns regarding the administration of blood pressure medication outside the physician's order parameters, and no additional information was provided before the survey exit.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications were kept in locked compartments and maintained under proper temperature controls. During a medication pass observation, a Certified Medicine Aide (CMA) left a medication cart unattended and unlocked in the hallway outside a resident's room. The unit nurse manager confirmed that the cart was unlocked and acknowledged that it should have been secured when the CMA walked away. The Director of Nursing (DON) was informed of this deficiency but provided no additional information. In another instance, a surveyor observed an insulin pen left unattended on a medication cart in the hallway outside a resident's room. The resident and their roommate were present in the room, but no nursing staff was in the area at the time. The nurse responsible for the medication cart returned after a few minutes and acknowledged the concern raised by the surveyor about leaving the insulin pen unattended. Additionally, the facility failed to maintain proper temperature controls in medication storage rooms. Observations revealed that the refrigerators used to store insulin had temperatures outside the recommended range. On one occasion, a refrigerator's thermometer read 30 degrees Fahrenheit, which is below the acceptable range for storing insulin. Another refrigerator had a temperature reading between 10-20 degrees Fahrenheit, with a large buildup of ice noted. The Assistant Director of Nursing and unit nurse manager confirmed these findings, and the DON was informed of the temperature issues in both medication room refrigerators.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that a resident requiring dental services received necessary or recommended dental care in a timely manner. The resident, who had been living in the facility for several years, reported experiencing mouth pain due to issues with gums and teeth. A dental examination conducted over a year prior revealed multiple retained roots, fractured teeth, and non-restorable caries, with a recommendation for surgical extraction at a hospital where the resident had previous extractions. However, there was no documentation indicating that the resident was sent to the hospital or any other dental institution for the recommended treatment. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were involved in reviewing the resident's medical records to determine if any further dental consultations had occurred. The ADON confirmed that the resident did not receive the recommended dental services due to insurance coverage issues, and no alternative services were sought. The new Nursing Home Administrator acknowledged that the facility should have sought alternative services when insurance coverage was a concern, indicating a lapse in providing necessary dental care to the resident.
Inaccurate Facility Assessment and Documentation Issues
Penalty
Summary
The facility failed to accurately assess the needs of its resident population, as evidenced during a recertification survey. During the entrance conference, the Nursing Home Administrator (NHA) was asked to provide a copy of the Facility Assessment. Upon review, it was found that the assessment inaccurately listed 'N/A' for the number of residents requiring ostomy care, despite the facility matrix indicating that at least one resident required such care. The NHA acknowledged the error, stating that the assessment was outdated and needed to be updated. Further interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and a unit manager revealed discrepancies in the facility's documentation process. The DON claimed that the assessment had been updated since April 2024, but was unable to provide an updated copy to the survey team. Despite multiple requests over several days, the DON was unable to produce the updated Facility Assessment, indicating a lack of proper documentation and communication within the facility's administrative processes.
Walk-in Freezer Safety Deficiency
Penalty
Summary
The facility failed to maintain the walk-in freezer in the kitchen in a safe operating condition. During a tour conducted with the Food Service Director, it was observed that frost had accumulated around the freezer door, and the door would not close and latch on its own. The surveyor noted that significant force was required to latch the door. The Food Service Director mentioned that a renovation was planned and indicated that the facility was old. This issue was later discussed with the Director of Nursing, who acknowledged the concern regarding the freezer's condition.
Failure to Provide Written Grievance Resolutions
Penalty
Summary
The facility failed to have a procedure in place to provide residents with written notifications concerning the resolution of grievances. This deficiency was identified during a review of 18 grievance forms written between October 2024 and January 2025, where none of the forms documented that the resident received or agreed to the resolution of their grievance. The forms had a designated space for the resident's signature and date, but this space was either signed by the Social Service Director or left blank. The Director of Social Services, who is responsible for the grievance process, reported that residents or their representatives were not issued a written decision on grievances. The Director of Nursing confirmed that the Social Service Director was signing in the space meant for the resident and was unaware that residents should be informed in writing of the grievance resolution. The facility's policy stated that a written decision should be issued to the resident or their representative at the conclusion of the investigation, which was not being followed.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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